Oklahoma > Workers Comp

Authorization For Attorney Representation CC-Form-71 - Oklahoma

Authorization For Attorney Representation Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-71 Attach to Entry of Appearance filed by Attorney Representative In re claim of: Full Name of WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY Injured Employee Beneficiary/Guardian in Death Claim Provider Social Security Number of Injured Employee or, if Death Claim, Deceased Employee (LAST 4 DIGITS ONLY) Name of Employer (Respondent) Commission File Number Date of Injury Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Group Self-Insurance Association [Attach to entry of appearance as provided in Commission Rule 810:2-1-10(b).] (name of party) designates the following attorney or law firm to serve my our authorized representative in the above referenced matter, to receive all notices in my our behalf and to provide as services in this matter, including the presentation of evidence relating to the claim, unless and until this authorization is terminated or withdrawn by further written notices or upon an order of withdrawal pursuant to the filing of a CC-Form-93 (Application and Order for Leave to Withdraw as Attorney of Record): AUTHORIZATION FOR ATTORNEY REPRESENTATION REPRESENTATIVE INFORMATION (Please type or print.) Full Name of Representative (Last, First, MI) Mailing Address Email Address Telephone Number (Area Code, Number and Extension ) FAX Number Firm Name City OBA # State Zip Administrative Workers' Compensation Act, 85A O.S., ยง6(A)(1)(a): "Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment ... shall be guilty of a felony." Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. NOTE: Both the designated representative and the client must sign and date this Authorization for Attorney Representation. injured employee beneficiary/guardian in death claim provider (if an individual, or the authorized agent of By signing below the agent of the respondent employer/carrier, who is making this designation, acknowledges the representative the provider) indicated above will represent them in the above referenced matter. By signing below, the representative accepts this designation. authorized The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Party's Signature Respondent Employer/Insurer Injured Employee Date Signed Beneficiary/Guardian in Death Claim Provider Print or Type Name of Party Signing Representative's Signature Print or Type Name of Representative Date Signed Created 2-18-14 American LegalNet, Inc. www.FormsWorkFlow.com
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